Whether you have to contend with the odd blinder of a chin spot, a cheek full of deep zits (why do they always congregate on one side?) or a forehead rash of whiteheads, acne can be a scourge, and there’s no denying how debilitating it can be – especially if you absolutely cannot help it.
Hormones, we’re looking at you.
Rather irritatingly, there are volumes of myths about hormonal acne (no, you don't have to live with it), but a shocking lack of information out there on how to sort it. For many reasons, not all of us want to take oral medications, and sometimes, benzoyl peroxide gels alone just don’t cut it.
This is something I know all too well. I suffered with acne on and off as a teenager but when I hit 25 it came back with a vengeance, no thanks to being diagnosed with hormone imbalance, polycystic ovary syndrome – a condition which affects 1 in 5 women in the UK. After countless failed trips to my GP, foolishly thinking they’d be the one to better inform me how to keep my hormones in check, I finally made my first ever pilgrimage to a dermatologist and my skin has never looked better.
Medication and an entirely new skincare routine helped me immensely, but there are so many other treatments worth trying, too. Refinery29 enlisted two of the best dermatologists in the acne business to help you get a handle on your hormonal breakouts once and for all.
First of all, what is hormonal acne?
"Fundamentally, all acne is hormonal," explains consultant dermatologist at Skin55 and author of The Skincare Bible, Dr. Anjali Mahto. "Skin concerns can often be attributed to hormonal changes that take place during the course of one’s life, and there are certain periods, namely puberty, pregnancy and the menopause, where this holds particularly true. Hormones can wreak havoc on the skin in a rather unpredictable manner during these times."
So what exactly are they?
"Hormones are chemical messengers that act on target bodily tissues," continues Dr. Mahto – something London-based consultant dermatologist, Dr. Justine Kluk, explains further. "Hormones known as androgens, for example testosterone, increase sebum production and cause thickening of the skin. These can contribute to pore-blocking and can trigger breakouts."
This also explains why you might notice more spots appearing close to your period. "About two-thirds of acne-prone women will note worsening of their acne typically occurring anywhere from a week to a few days before the start of their period," says Dr. Mahto. "This is because female hormones are at their lowest, and male hormones (androgens) are higher at these points."
Interestingly, many of us think of hormonal acne as red raw cysts, but according to Dr. Kluk, there are heaps of forms your hormonal spots can take. "Hormonal acne isn’t so much a description of what acne looks like, rather a reflection of what may be causing it," Dr. Kluk explains. "Blackheads, whiteheads and cysts are all possibilities." Who knew?
"It often has a distinctive pattern though," adds Dr. Kluk, "with a tendency for the spots to appear on the lower face, neck, chest, and upper back."
Could my hormonal acne be a result of polycystic ovary syndrome?
"PCOS, or polycystic ovary syndrome, has been estimated to affect approximately 8% of women of reproductive age, making it very common indeed," explains Dr. Kluk.
"Acne is a possible manifestation in women with PCOS and between 19% to 37% of women with moderate to severe acne meet the criteria for the condition," she continues. So when should you get checked out?
"The suspicion should be raised if acne originates or persists into adulthood and is resistant to conventional therapies. Other symptoms include reduced ovulation leading to irregular periods, ovarian cysts which can be seen on ultrasound scanning and signs of raised androgen levels (male hormones) such as oily skin, increased body hair, and thinning of scalp hair."
How to get rid of hormonal acne
So now we know exactly what causes hormonal acne, here's how to best manage it.
Hormonal therapies – the combined contraceptive pill (aka the pill)
"The combined oral contraceptive pill, aka 'the pill' can be used to control acne in women requiring contraception," explains Dr. Mahto.
"It works because oestrogen in the contraceptive pill reduces sebum and androgen production. Data suggests that it can take up to three months to see skin benefits from the contraceptive pill and certain pills, such as Yasmin and Dianette, are seen as more 'skin-friendly'."
If you think the pill might be a good option for you, visit your GP, who will talk you through the pros and cons before helping you choose the right one.
In many instances, doctors can be reluctant to prescribe it, as it's an 'off-label' drug. This means it was licensed for another reason, in this case to treat high blood pressure and heart failure. Aside from this, spironolactone is an androgen-blocker, which means it slows down the production of male hormones, which are responsible for excess oil and breakouts. "Spironolactone has a useful role in female adults and those with PCOS especially," explains Dr. Mahto. "It should only be prescribed by a specialist with extensive experience of its use."
Make an appointment with a dermatologist to discuss whether spironolactone is right for you, depending on your medical history and lifestyle.
Isotretinoin (aka Roaccutane)
"Isotretinoin is a vitamin A‑based drug that is highly effective in severe, recalcitrant acne with signs of scarring," says Dr. Mahto. "It also has a role in acne that is resistant to treatment with other agents, relapses quickly after completion of antibiotic therapy or is having a profound psychological impact. In the UK, it can only be prescribed under the supervision of a dermatologist," she adds.
So how exactly does it work? Well, it stops oil glands from producing too much sebum and speeds up shedding of dead skin cells, which both work to prevent blocked pores that lead to spots. There are side-effects, though. Dry, cracked skin is common on isotretinoin and close supervision by a specialist is largely required.
Skincare – retinoids
Often touted as the gold standard in anti-ageing skincare, retinoids also play a significant role in treating acne.
"Retinoids are vitamin A-based products that essentially stop skin cells from becoming sticky," says Dr. Mahto. "In other words, they reduce the blockage of pores and prevent things like blackheads from forming."
But there are some side-effects.
"When you first use retinoids, it is very common for skin irritation and redness to occur, so I usually recommend that treatment needs to be built up gradually." In other words, alternate using a retinoid cream or serum two to three times a week, taking a break in between. And as retinoids are not photostable, it's best to use them in the evening, rather than in the day, when sunlight can break them down. Your skin cells regenerate at this time, too, so you're likely to see better results.
No thanks to hormones, oil production can go into overdrive and, mixed with dead skin cells, it's a recipe for acne. But incorporating acids into your evening skincare routine could be the answer to minimising those breakouts.
The most common acid in skincare is glycolic acid. It dissolves the upper layer of skin cells and prevents spots from cropping up when used consistently. Swiped over clean skin, 6% glycolic acid in Nip + Fab's Glycolic Fix Liquid Glow, £19.95, dissolves the paste-like mixture of oil and dead skin cells that leads to spots, while improving the pigmentation they often leave behind.
Another helpful acne-buster is salicylic acid. Like lactic and glycolic acid, it exfoliates the top layer of the skin but penetrates deeper into the pores to dissolve sebum, which means it's super effective on things like blackheads.
Applied to just-cleansed skin and used as an overnight toning treatment, Paula's Choice Skin Perfecting BHA Liquid Exfoliant, £26, works wonders to unplug pores and refine skin texture.